Download Orthodontic Consent Form - Fairmilehead Dental Practice

PATIENT’S INFORMED CONSENT AND AGREEMENT
REGARDING ORTHODONTIC TREATMENT
I UNDERSTAND that treatment of dental conditions pertaining to ORTHODONTIC TREATMENT (straightening or
repositioning of teeth) includes certain risks and potential unsuccessful results. Even though great care and
diligence will be used in treatment, no promises or guarantees for desired results can be made nor expected.
DEVICE DESCRIPTION
Removable orthodontic appliance
These consist of removable plastic and wire braces which are designed to undertake more simple orthodontic
corrections. These include simple tooth movement, expansion and habit breakers. They are also used as retaining
braces after more involved treatment with fixed braces has been completed.
A specially designed combination of an upper and lower removable brace can be used to functionally stimulate jaw
growth.
Fixed orthodontic appliance
These consist of metal or ceramic attachments called brackets and bands, which are fixed to the outside of the
teeth with special adhesives. A wire is then tied into the brackets which imparts the necessary force required to
biologically align the teeth.
The fixed orthodontic braces allow for full three dimensional control of all the tooth positions in the mouth and are
used to correct more severe problems such as complete realignment of the bite, severe crowding of the teeth and
other tooth positions which can severely affect facial appearance.
Regular visits at about 6-8 weekly intervals are required in order to reactivate the fixed appliance by either
tightening the existing wire or replacing it with a slightly more active one. A course of treatment can take from 15 to
24 months to complete.
A period of retention with removable braces will always follow and is normally monitored for about a year. A fixed
retainer, in the form of a wire bonded behind the front teeth, is often used as an alternative to ensure long-term
stability of the lower front teeth. Patients are encouraged to continue wearing their retainers on a part-time basis
for as long as possible. The following points should be noted.
1.
Complete co-operation of the patient is essential. Once treatment is begun, each appointment must be
attended as scheduled. Each delayed or missed appointment will prolong the time necessary to complete
treatment (which can never be precisely determined) and may create problems making it impossible to
achieve the desired results.
2. Instructions must be diligently followed. There will be instructions given concerning special oral hygiene
measures which must be followed. Also, as treatment progresses, certain adjunctive appliances may be
necessary. Instructions will be given as to their care and use which must also be followed exactly.
Informational and instructional literature will be given. It is the responsibility of the patient to thoroughly
study and understand this material.
3.
Decalcification (permanent markings on the teeth), decay, and/or gum disease can occur if teeth are
not brushed properly and thoroughly during the treatment period. Sweets and between meal snacks must
be eliminated. If desired results are to be achieved, this is absolutely necessary. Continuing check-ups and
dental care from the patient’s general dentist during the course of treatment is essential.
4. Teeth may become non-vital. This is always a possibility, with or without orthodontic treatment. Trauma
from a blow, deep fillings etc, may cause the nerve tissue in a tooth to die. This can happen over a long
period of time. Even though this problem may exist, it may be undetectable at the beginning of orthodontic
treatment but, through tooth movement, it may exhibit itself. Root canal treatment may then become
necessary in order to preserve the tooth or teeth.
5. Root resorption is a condition where roots may become shortened during treatment. Under healthy
conditions, this is no serious disadvantage. However, if gum disease occurs in later life, the longevity of the
teeth could be compromised. Other conditions can cause root resorption such as trauma, cuts, impaction,
endocrine disorders, or idiopathic (unknown) reasons.
6. Temporomandibular Joint (TMJ) dysfunction can occur before, during or after orthodontic treatment.
Many times the TMJ, even though the damage had begun long before the orthodontic treatment, because
of the subtle changes in the bite through treatment, symptoms of this damage (such as clicking, popping,
crackling, pain, headaches etc), may then become evident. Even though there were no apparent symptoms
previously, these may begin to exhibit themselves during treatment. Should such symptoms occur, it may
7.
be necessary for the patient to be referred to a TMJ specialist.
Shifting of teeth might occur after braces are removed. For this reason, retainers are constructed which
must be diligently worn for a period of time which will vary between patients. Retainers are made of
materials that are subject to breakage no matter how well constructed. Retainers must be handled and
used carefully. Repair charges may be made. Instructions will be given concerning these appliances.
I recognise that it is my responsibility to follow instructions completely and seek attention in a timely
manner should any unexpected problems occur by informing Fairmilehead Dental Practice immediately. I
must explicitly follow any instructions, either written or oral, which have been given to me relating to this
orthodontic treatment.
INFORMED CONSENT
I have been given the relevant information, including leaflets, and the opportunity to ask any questions regarding
the nature and purpose of orthodontic treatment and have received answers to my satisfaction. I have been given
the alternative of seeking care with an orthodontic specialist. I do voluntarily assume any and all possible risks,
including risk of substantial harm, if any, which may be associated with any phase of this treatment in the hope of
obtaining the desired potential results, which may or may not be achieved. No guarantees or promises have been
made to me concerning any results from treatment. The fee(s) for these services have been explained to me and I
accept them as satisfactory. By signing this form, I accept all terms and conditions expressed within it and freely
give my consent to authorise
Dr ___________________________________ and any and all associates necessary in rendering services that he/she
deems necessary or advisable for this subject orthodontic treatment.
PATIENT’S NAME (Please print)
______________________________
SIGNATURE OF PATIENT, LEGAL GUARDIAN
OR AUTHORISED REPRESENTATIVE
_______________________________
DATE _______________
WITNESS TO SIGNATURE
_______________________________
DATE _______________